Negative Pressure or Positive Pressure Isolation Rooms

CHS19/047

Canberra Health Services

Operational Procedure

Negative Pressure or Positive Pressure Isolation Rooms. Operation, Performance Monitoring and Maintenance

Contents

Contents1

Purpose2

Scope2

Section 1 – Roles and Responsibilities2

Section 2 – Background3

Section 3 – Maintenance5

Section 4 – Operation6

Implementation6

Related Policies, Procedures, Guidelines and Legislation7

References7

Definition of Terms8

Search Terms8

Attachments9

ATTACHMENT A. Isolation Rooms10

ATTACHMENT B. UCH Negative Pressure Room Instructions and Check list12

ATTACHMENT C. Negative pressure analogue gauge:15

ATTACHMENT D. Negative pressure analogue gauge DAILY CHECK:16

ATTACHMENT E. Positive pressure analogue gauge:18

ATTACHMENT F. Positive pressure analogue gauge DAILY CHECK:19

ATTACHMENT G. Negative pressure or Positive pressure electronic gauge:21

ATTACHMENT H. Negative pressure or positive pressure electronic gauge DAILY CHECK:23

Purpose

To provide Canberra Health Services (CHS) employees relevant guidelines to appropriately and safely operate, monitor performance, and plan maintenance for negative pressure or positive pressure isolation rooms.

This procedure should be read in conjunction with the Healthcare Associated Infection (HAI) Procedure 2.6.3 Airborne Precautions.

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Scope

The procedure pertains to all Canberra Health Services (CHS) staff.

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Section 1 – Roles and Responsibilities

Infection Prevention and Control

Infection Prevention and Control are required to know the location and types of all negative pressure and positive pressure rooms throughout CHS (Attachment A and B) and to assist the Bed Access Unit in correctly allocating rooms to patients with an infectious disease.

Infection Prevention and Control should be notified when a negative pressure or positive pressure room fails to achieve required pressure.

Facilities Management

Facilities Management are to ensure that ongoing maintenance and testing of negative pressure and positive pressure rooms are undertaken and reported to National Safety and Quality Health Service Standards Healthcare Associated Infections Committee.

Facilities Management are responsible for the education of health care workers in the reading and interpreting of monitoring instrumentation regarding pressure variants, system functions and interpretation of the alarming system.

Health Care Workers

Ward Clinical Nurse Consultants/ Clinical Midwife Consultants (CNC/CMCs) are responsible for ensuring ward/unit performance monitoring and compliance to the procedure. Health care workers are expected to maintain a process of daily monitoring, recording and reporting of non-compliance in accordance with this procedure.

Health care workers are to report detected errors to Facilities Management as they occur.

CNC/CMCs and Bed Management are to allocate correct isolation room in accordance with clinical isolation requirements.

Health care workers should be suitably educated in the reading and interpreting of monitoring instrumentation regarding pressure variants and system functions. This shall be Ward/Unit specific induction that includes education on the interpretation of the alarming system. Clinical Development Nurses are to facilitate 6 monthly in-service training sessions.

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Section 2 – Background

Isolation for Infectious/Immunocompromised People

Some diseases or conditions require more than Standard Precautions to protect staff and patients.

Patients with these diseases/conditions will require physical separation from other patients by placing them in a single room to reduce contact and/or airborne spread of the infective agent.

Negative Pressure or Positive Pressure Isolation Rooms

Selected patient rooms have been provided with air pressure control to maintain either a negative or positive air pressure.

Room air pressure, or pressure differential, is created when one space (corridor/anteroom) is at a different pressure than an adjoining space (patient room). When a pressure differential is created between two spaces, air is forced to flow from the higher pressure space to the lower pressure space. The direction of air flow is one component of proper room air pressure. The second component of room air pressure is the speed or how fast is the air moving between the two spaces.

Negative room pressure in a room is supplied by the air ventilation system that generates negative pressure to allow air to flow into the isolation room, but not escape from the room. Air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air (e.g. airborne microorganisms) from escaping the room, such as entering the corridor/anteroom. Typically air flows from the corridor/anteroom into the negative pressure room, ensuring that contaminated air cannot escape from the negative pressure room to other parts of the ward. This technique is used for isolation of patients with airborne contagious diseases, such as Tuberculosis, Varicella (chicken pox) and Measles.

Positive room pressure in a room is supplied by the air ventilation system that generates positive pressure greater than the environment that surrounds that room. This technique is used to prevent transmission of pathogens from the outside environments to profoundly immune-compromised patients, such as severely neutropenic patients, allogeneic bone marrow recipients. Air will flow out of the room instead of in, preventing any airborne microorganisms (e.g. bacteria, etc.) from entering the room.

Note:

If an immune-compromised patient has an infection transmitted by the airborne route (e.g. chickenpox, measles, tuberculosis) then they may pose a risk to other immune-compromised patients if placed in a positive pressure room. Urgent advice should be sought from Infection Prevention and Control or the on-call Infectious Diseases physician.

Negative Pressure or Positive Pressure Isolation Room Features

· The negative pressure room will continue negative air flow at all times.

· The positive pressure room will continue positive air flow at all times.

· All negative pressure or positive pressure rooms will have pressure alarms installed.

· There is no manual over-ride for adjusting the pressures in these rooms.

· An alarm indication is displayed on the Annunciator panels and staff station terminal within the respective ward identifying the room in which the pressure loss/gain has occurred.

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Section 3 – Maintenance

Preventative Maintenance Schedule

Routine performance monitoring and maintenance for Isolation Rooms are critically important due to the high risk of transmission and possible outbreaks if systems are not adequately maintained.

There should be a documented Preventative Maintenance Schedule for each negative pressure or positive pressure isolation room. A documented record of maintenance activities shall be available from Facilities Management and Maintenance for inspection when required.

Maintenance Program

There shall be a scheduled Maintenance Program at not greater than 13-week intervals to check and ensure performance of negative pressure or positive pressure isolation rooms. The following should be checked and a corresponding record of maintenance shall be documented and available:

· Air change rate

· Supply and exhaust quantities

· Terminal high efficiency particulate air (HEPA) filters

· Supply air diffuser or registers, return/exhaust air grilles and ductwork

· Room pressure gauges and alarms

· Supply and exhaust fans and dampers

· Room seals and door closer

· Clinical hand basin and ensuite plumbing

· Room signage

A Facilities Maintenance schedule for the exhaust grills and filters is available on request from Facilities Management and Maintenance. Facilities Management and Maintenance or Maintenance and Engineering staff will contact ward staff when this is due.

In some clinical areas the alarm will appear on the Building Management System if there are any problems with the negative or positive pressure isolation mode. Staff in the area will be alerted to this by Facilities Management and Maintenance or Maintenance and Engineering staff, and again when the problem has been resolved.

Emergency Electric Power Supply

A back up emergency electric power supply shall be available to ensure fans, alarms and monitoring systems do not fail if main supply is disrupted.

Ward/Unit Performance Monitoring

The nursing and midwifery staff need to maintain a process of daily monitoring and recording of the pressure indicated on the pressure gauge located just outside the entrance to the room. The doors of the room (and the anteroom) need to be closed prior to the monitoring of the pressure.

Recording system needs to indicate:

· Daily room pressure checks

· Alarming system functional = YES/NO (if NO, maintenance request completed = YES/NO)

· Annual Service and Maintenance - label – dated and signed.

· A documented record of daily performance check shall be available and kept at the staff station.

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Section 4 – Operation

Negative pressure or positive pressure isolation room

When the room is used for a patient that requires a negative pressure or positive pressure isolation room, the key controlled alarm is to be activated.

When the negative pressure or positive pressure isolation room is not used for a patient that requires a negative pressure or positive pressure isolation room the key controlled alarm can be deactivated.

Each negative pressure or positive pressure isolation room is fitted with a functional pressure gauge outside the room. The pressure gauge is either

1. Negative pressure analogue gauge (Attachment C & D)

or

2. Positive pressure analogue gauge (Attachment E & F)

or

3. Negative pressure or positive pressure electronic gauge (Attachment G & H)

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Implementation

This procedure is to be communicated to all CHS staff via the Deputy Director General email alerts notifying staff of new Policy. Staff will be reminded by email each year of the procedure around the management of negative and positive pressure isolation rooms. In addition, this will be forwarded to the Bed Access Unit to allow appropriate bed management of admitted patients.

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Related Policies, Procedures, Guidelines and Legislation

Policies

· Patient Identification and Procedure Matching Policy

Procedures

· Healthcare Associated Infections Clinical Procedure

· Patient Identification and Procedure Matching Procedure

· Infectious Threats Operations Manual

· Infectious Threats Clinical Procedure

· Control of Tuberculosis Procedure

· Cancer and Blood Disorders – care of paediatric patients (infants, children and adolescents

Standards

· Standards Australia, 2003, Handbook HB 260: Hospital acquired infections - Engineering down the risk

· Standards Australia, 2012, AS 1668.2: The use of ventilation and air-conditioning in buildings. Part 2: Mechanical ventilation in buildings.

· Standards Australia, 2000, AS 1807.6: Cleanrooms, workstations, safety cabinets and pharmaceutical isolators - Methods of test. Method 6: Determination of integrity of terminally mounted HEPA filter installations.

· Standards Australia, 2000, AS 1807.10: Cleanrooms, workstations, safety cabinets and pharmaceutical isolators - Methods of test. Method 10: Determination of air pressure of cleanrooms and pharmaceutical isolators.

Legislation

· Health Records (Privacy and Access) Act 1997

· Human Rights Act 2004

· Work Health and Safety Act 2011

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References

Australian Commission on Safety and Quality in Health Care. (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. National Health and Medical Council. https://www.nhmrc.gov.au/guidelines-publications/cd33

Australasian Health Infrastructure Alliance (AHIA). Australasian Health Facility Guidelines (AusHFG) 2016. Part D - Infection Prevention and Control. https://aushfg-prod-com-au.s3.amazonaws.com/Part%20D%20Whole_7_1.pdf

Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17): http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

Victorian Advisory Committee on Infection Control, 2007, Guidelines for the Classification and Design of Isolation Rooms in Health Care Facilities.

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Definition of Terms

Air changes - The ratio of the volume of air flowing through a space in a certain period of time (that is, the airflow rate) to the volume of that space (that is, the room volume). This ratio is usually expressed as the number of air changes per hour (ACHR).

Air Purification - a High Efficiency Particulate Air (HEPA) filter that purifies air from the atmosphere and removes solid particulates such as dust, pollen, mould, and bacteria from the air. To qualify as HEPA by standards, an air filter must remove (from the air that passes through) 99.97% of particles that have a size of 0.3 µm. The system is controlled automatically and requires no input from occupants. Air purification is located to the positive air pressure rooms.

Anteroom - A small room leading from a corridor into an isolation room. This room can act as an anteroom and prevent the escape of contaminants from the isolation room into the corridor

Differential pressure gauge - A pressure gauge that will display the difference in pressure between one port on the gauge and the other. Normally placed to measure the difference in pressure between two rooms. Pressure is measured in Pascals (Pa).

Pascal (Pa) is the unit of pressure or stress in the International System of Units (SI). 

Health care workers (HCW) – All clinical staff including students.

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Search Terms

Negative and positive pressure Isolation Room, Infection Control, Negative pressure room, positive pressure room, Isolation Room

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Attachments

Attachment A - Isolation Rooms

Attachment B - UCH Negative Pressure Room Instructions and Check list

Attachment C - Negative pressure analogue gauge

Attachment D - Negative pressure analogue gauge daily check

Attachment E - Positive pressure analogue gauge

Attachment F - Positive pressure analogue gauge daily check

Attachment G - Negative pressure or positive pressure electronic gauge

Attachment H - Negative pressure or positive pressure electronic gauge daily check

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

This document supersedes the following:

Document Number

Document Name

ATTACHMENT A. Isolation Rooms

Types of Isolation Rooms:

There are four types of Isolation Rooms used for infection control.

Australasian Health Facility Guidelines (AusHFG)

Standards Australia HB260, 2003

Class S - Standard

Type 4 - Standard isolation

Class P - Positive pressure

Type 3 - Patient protection

Class N - Negative pressure

Type 5 - Respiratory isolation

Class Q - Quarantine

Type 5 plus airlock - Quarantine isolation

Functional Classification of Isolation Rooms:

Class P / Type 3

Class S / Type 4

Class N / Type 5

Class Q / Type 5 plus airlock

Key ventilation criteria

Greater air pressure in the room than in the corridor.

No air pressure difference between room and the adjacent corridor.

Lower air pressure in the room than in the adjacent corridor or anteroom.

Lower air pressure in the room than in the adjacent airlock.

Transmission based rationale

To prevent transmission of pathogens from the outside environment to profoundly immunocompromised patients.

To prevent contact or droplet transmission.

To prevent airborne transmission.

Quarantine of patients with highly transmissible pathogens to prevent airborne transmission.

Examples for use

(noting this is not a complete list)

To prevent infections such as aspergillus (fungal infection) in allogeneic bone-marrow transplant recipients.

VRE / MRSA

Gastroenteritis

Cutaneous anthrax

Hepatitis A

Measles and Varicella, suspected or proven.

Pulmonary or laryngeal tuberculosis.

Suspected contact of measles, Varicella, and SARS if symptomatic.

Highly infectious pathogens such as haemorrhagic fevers, pneumonic plague.

Reference: Australasian Health Facility Guidelines Part D - Infection Prevention and Control March 2016

For further information refer to section B5.2 of NHMRC, 2010, Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010).

Target room ventilation parameters of Isolation Rooms used for infection control:

Room Classification

Supply air quantity

Exhaust air quantity

Room Differential Pressure (DP) to surroundings

Calculated Air Changes per Hour (ACH)

Positive pressure

> 15 ACH effective

10% lower than Supply Air quantity

2 Pa to 10PA Positive

> 15 ACH

Standard

> 6ACH

10% higher than Supply Air quantity

2 Pa to 10PA Negative

> 6ACH

Negative pressure

> 15 ACH effective

10% higher than Supply Air quantity

5 Pa to 10PA Negative

> 15 ACH

ATTACHMENT B. UCH Negative Pressure Room Instructions and Check list

Refer to the Alarm Panel Diagram below for display ranges in normal operation

Initiating the alarm for patient requiring negative pressure isolation

Step

Action

1

· To set up room before admitting the patient, the alarm is to be activated.

· To confirm the alarm is activated open the respective doors – the displayed pressures will rise to 0 Pascals (Pa). Allow the doors to remain open for up to 2 minutes (threshold period to prevent nuisance alarms)

· Alarms must annunciate from the respective alarm panels

· Contact the Help Desk on Ext 47000 where alarms fail to annunciate (priority 1)

· With the alarm activation available, close both doors (anteroom and patient room)

· The pressures displayed on each panel should fall within the ranges shown on the diagram below. Contact the Help Desk if displays are not within the ranges specified.

2

· Once the patient is in the room, access should be via the anteroom door when possible.

· Ensure both main door and anteroom door remain closed at all times.

3

If the negative pressure room alarm is no longer required, (i.e. patient is determined to be non-infectious) contact the Help Desk to mute the alarm and record the same on the log sheet

Negative pressure room process when patient who had a clinical requirement for a negative pressure room is discharged.

The following steps must be undertaken following discharge of an infectious patient.

The room CANNOT BE USED FOR NEW ADMISSIONS until the steps have been undertaken in the following order.

4

When the patient is discharged, close the door and leave vacant for 30 minutes prior to terminal clean (to ensure transmission is reduced).

5

If Ward/unit staff or contracted staff enter the room during this 30 minutes period they must wear a N95/P2 respirator particulate mask.

6

Contact the Help Desk to mute the alarm

7

Complete terminal clean

UCH Negative Pressure Room Checklist

Ward /Unit:

Month / Year:

Room Number:

Negative pressure:

Date

Pressure reading

RN/M Initials

Corrective Action

Date

Pressure reading

RN/M Initials

Corrective

Action

1

17

2

18

3

19

4

20

5

21

6

22

7

23

8

24

9

25

10

26

11

27

12

28

13

29

14

30

15

31

16

CN/MC Comments:

Date:

CN/MC signature after monthly review and check:

Date:

Negative Pressure Room Digital Alarm Display – Operating Range

Patient Room

15 – 18 Pascals (Pa)

Anteroom

7 – 9 Pascals (Pa)

ATTACHMENT C. Negative pressure analogue gauge:

Alarm Panel -

Red light indicate insufficient Negative pressure inside room

Pressure Gauge –

Sufficient Negative pressure= between -5 to -10 Pascals.

Pressure Gauge –

Insufficient Negative pressure = less than -5 Pascals

Initiating key controlled alarm for patient requiring Negative pressure Isolation

Step

Action

1

· To set up room before admitting the patient, the alarm is to be activated.

· To enable the alarm of the Negative pressure room, access the alarm key. The key to enable the alarm is located with the ward/unit DD keys.

· Close the door to the Negative pressure room.

· Complete the procedure for checking negative room as in flowchart of daily Check Sheet.

· Start the alarm by turning the key/switch from ‘off’ to ‘on’.

· Remove the key - the Negative pressure room alarm has now been activated.

· If this does not occur contact FM (out of hours via switch board).

2

· Once the patient is in the room, access should be via the anteroom door when possible.

· Ensure both main door and anteroom door remain closed at all times.

N.B. The anteroom doors are designed to allow only one door to be opened at any one time.

3

If the Negative pressure room alarm is no longer required, (i.e. patient is determined to be non-infectious) turn the key for the alarm on the panel to ‘normal/off’.

Negative pressure room process when patient who had a clinical requirement for a Negative pressure room is discharged.

The following steps must be undertaken following discharge of an infectious patient.

The room CANNOT BE USED FOR NEW ADMISSIONS until the steps have been undertaken in the following order.

4

When the patient is discharged, close the door and leave vacant for 30 minutes prior to terminal clean (to ensure transmission is reduced).

5

If Ward/unit staff or contracted staff enter the room during this 30 minute period they must wear a N95/P2 respirator particulate mask.

6

Using the alarm key, turn the key to alarm off position.

7

Complete terminal clean

ATTACHMENT D. Negative pressure analogue gauge DAILY CHECK:

Ward /Unit:

Month / Year:

Room Number:

Negative pressure:

Date

Pressure reading

RN/M Initials

Corrective Action

Date

Pressure reading

RN/M Initials

Corrective

Action

1

17

2

18

3

19

4

20

5

21

6

22

7

23

8

24

9

25

10

26

11

27

12

28

13

29

14

30

15

31

16

CN/MC Comments:

Date:

CN/MC signature after monthly review and check:

Date:

NOTE: The Negative pressure analogue gauge is near the door of the positive pressure room.

ATTACHMENT E. Positive pressure analogue gauge:

Alarm Panel -

Red light indicate insufficient Positive pressure inside room

Pressure Gauge –

Sufficient Positive pressure = between +2 to +10 Pascals.

Pressure Gauge –

Insufficient Positive Pressure = less than +2 or greater than +10 Pascals

Initiating key controlled alarm for patient requiring positive pressure Isolation

Step

Action

1

· To set up room before admitting the patient, the alarm is to be activated

· To enable the alarm of the Positive pressure room, access the alarm key. The key to enable the alarm is located with the ward/unit DD keys.

· Close the door to the Positive pressure room.

· Complete the procedure for checking Positive pressure as in flowchart of daily Check Sheet.

· Start the alarm by turning the key/switch from ‘off’ to ‘on’.

· Remove the key - the Positive Pressure room alarm has now been activated

· If this does not occur contact FM (out of hours via switchboard).

2

If the positive pressure room alarm is no longer required, turn the key for the alarm on the panel to ‘normal/off’.

Positive pressure room process when patient who had a clinical requirement for a Positive pressure room is discharged

Step

Action

3

Using the alarm key, turn the key to alarm off position.

4

Standard cleaning required

ATTACHMENT F. Positive pressure analogue gauge DAILY CHECK:

Ward /Unit:

Month / Year:

Room Number:

Positive Pressure:

Date

Pressure reading

RN/M Initials

Corrective Action;

Date

Pressure reading

RN/M Initials

Corrective

Action;

1

17

2

18

3

19

4

20

5

21

6

22

7

23

8

24

9

25

10

26

11

27

12

28

13

29

14

30

15

31

16

CN/MC Comments:

Date:

CN/MC signature after monthly review and check:

Date:

NOTE: The Positive pressure analogue gauge is near the door of the positive pressure room.

ATTACHMENT G. Negative pressure or Positive pressure electronic gauge:

E.g. used in Centenary Hospital for Women and Children (CHWC)

Electronic Gauge Pressure Alarm

Initiating key controlled ‘Pressure Alarm’ for patient requiring Negative pressure or Positive pressure rooms

Step

Action

1

· To set up room before admitting the patient, the ‘Pressure Alarm’ is to be activated.

· To enable the ‘Pressure Alarm’ of negative pressure or positive pressure room, use the alarm key. The key to enable the alarm is located with the ward/unit DD keys.

· Close the door to the pressure room.

· Complete the procedure for checking negative pressure or positive pressure room as in flowchart of DAILY CHECK sheet.

· To enable the alarm by turning the key/switch from ‘Disabled’ to ‘Enable’.

· Remove the key - the negative pressure or positive pressure room alarm has now been activated.

· If this does not occur contact Facilities Management and Maintenance (out of hours via switch board).

Negative pressure room process only

2

· Anterooms are only required for negative pressure rooms.

· The anteroom doors are designed to allow only one door to be opened at any one time.

· Once the patient is in the room, access should be via the anteroom door whenever possible.

· Ensure both main door and anteroom door remain closed at all times.

Negative pressure room process when patient who had a clinical requirement for a negative pressure room is discharged.

3

· When the patient is discharged, close the door and leave vacant for 30 minutes prior to terminal clean.

4

· If Ward/unit staff or contracted staff enter the room during this 30 minutes period they must wear a N95/P2 respirator particulate mask.

5

· Complete terminal clean

Positive pressure room process when patient who had a clinical requirement for a Positive pressure room is discharged

6

· Using the alarm key, turn the key to alarm ‘Disabled’ position.

7

· Standard cleaning required

ATTACHMENT H. Negative pressure or positive pressure electronic gauge DAILY CHECK:

Ward /Unit:

Month / Year:

Room Number:

Positive pressure or Negative pressure:

Date

Green light is on. ‘Normal’

RN/M Initials

Corrective Action

Date

Green light is on. ‘Normal’

RN/M Initials

Corrective

Action

1

17

2

18

3

19

4

20

5

21

6

22

7

23

8

24

9

25

10

26

11

27

12

28

13

29

14

30

15

31

16

CN/MC Comments:

Date:

CN/MC signature after monthly review and check:

Date:

NOTE: The Indication Panel is near the door of the negative pressure or positive pressure room.

Checking the Negative Pressure of the room

Close the door to the rooms. Allow at least 5 minutes.

Pressure readings are between ranges

-7 to -9 Pascals. (Pa) to the ANTE ROOM

- 15 to -18 Pascals (Pa) to the PATIENT ROOM

Pressure reading correct, no corrective action required.

Inform area CN/MC;

Contact Help Desk on ext 47000

Document below

Negative pressure reading are outside ranges

Checking the Negative Pressure of the room

Close the door to the room. Allow at least 5 minutes.

Pressure reading is between -5 to -10 Pascals.

Pressure reading correct, no corrective action required.

Inform area CN/MC

Complete urgent maintenance request through MyFM

Contact Infection Prevention and Control Department

Document below

Negative pressure is outside

-5 Pa to -10 Pa, that is less than -5 Pascals

Checking the Positive Pressure of the room

Close the door to the room. Allow at least 5 minutes.

Pressure reading is between +2 to +10 Pascals.

Pressure reading correct, no corrective action required.

Inform area CN/MC;

Complete urgent maintenance request through MyFM

Contact Infection Prevention and Control Department

Document below

Positive Pressure is less than +2 or greater than +10 Pascals

Checking the Negative pressure or Positive Pressure of the room

Close the door to the room. Allow at least 5 minutes.

NORMAL: Green light indicator is on. .

Pressure reading correct, no corrective action required.

ALARM: Red light is on

Inform area CN/MC;

Complete urgent maintenance request to MYFM

Contact Infection Prevention and Control Department

Document below

Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHS19/047

1

16/04/2019

01/01/2022

NMPSS

1 of 23

Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register